Harm Reduction and Abstinence—More Alike Than Different?

Colleen Anne Dell, PhD

Reprinted from "Aboriginal People" Visions Journal, 2008, 5 (1), p.  21-22

Alcohol and drugs have been a destructive influence in the lives of many First Nation, Inuit and Métis people in Canada, including in British Columbia. The forced loss of language, culture, land, tradition and identity has harshly affected the health and well-being of the original—Aboriginal—peoples. For some, this has resulted in mental health and addiction concerns, such as drug abuse.

A growing concern today is the injection of drugs like cocaine and heroin. Sharing the needles used to inject these drugs is a key mode of transmission for HIV among Aboriginal peoples in Canada.1 A recent study of Vancouver’s Downtown Eastside found that over a four-year period “18.5 percent of Aboriginal men and women who injected such drugs as cocaine and heroin became HIV-positive, compared with 9.5 percent of non-Aboriginal intravenous drug users.”2 A further study within Vancouver found that Aboriginal women who inject drugs are reported to die from HIV/AIDS, drug overdose and homicide at nearly 50 times the province’s general female population.3

A hotly debated question is whether harm reduction should be a part of the solution to this serious health concern. For many, this is a hard question to answer, because most people don’t fully understand, or are unwilling to look at, what harm reduction truly is.

What is harm reduction anyway?

For many people, the first thing that comes to mind when they think of harm reduction is Vancouver’s supervised injection facility (SIF). This is likely because that’s where most of the media attention has been placed. The public is receiving a large amount of information that pits moral arguments against research that supports the effectiveness of the SIF. For example, health minister Tony Clement commented to the Canadian Medical Association that doctors who support the use of the SIF lack medical ethics.4 The result is confusion on the part of the public about both the morality and the effectiveness of harm reduction.

There is likewise confusion when harm reduction measures are considered by Aboriginal peoples. Some First Nation, Inuit and Métis people maintain that harm reduction policies and practices go against their customs, traditions and beliefs. They believe using mind-altering substances causes a person to be “out of balance.” Others, however, consider that there are similarities between a harm reduction philosophy and traditional Aboriginal values. For example, respect is a traditional Aboriginal teaching—and respecting the choices of individuals, families and communities and “where they are at” is a premise of harm reduction.

In fact, the concept of choice underpins a harm reduction philosophy. Harm reduction policies and programs acknowledge that people and their communities are the ‘experts’ on their own experiences. As experts, they are best positioned to decide how to reduce the harm they experience because of substance abuse. Consider, for example, the Quesnel Tillicum Society Native Friendship Centre in northern British Columbia. Based on a need identified within and responded to by the community, the centre provides needles, condoms, swabs and needle exchange containers at no charge to community members.

Harm reduction, at its core, is simply a practice or strategy that reduces the harms individuals face because of their problematic use of substances.

Opposites? Or is one an aspect of the other?

From university classrooms to the front line in the addictions field, people too often think of harm reduction as the opposite of abstinence (i.e., not using any substances at all). In practice, however, harm reduction and abstinence actually have a core goal in common. They both aim to help people reduce the harms they experience because of their substance use.

Where the two philosophies are commonly believed to differ is in the concept of choice. While choice is a foundation of the harm reduction approach, it’s not as apparent with an abstinence-based approach. One reason for this, among Aboriginal peoples and communities, is the historical support for abstinence-based approaches. Abstinence has been favoured because the impact of alcohol and drugs has been devastating. It’s been thought that it’s better not to use at all than to use in a safer way. Also, the main source of treatment in Canada is offered by the National Native Alcohol and Drug Abuse Program (NNADAP). NNADAP was created nearly a quarter of a century ago when abstinence-based models were the norm.

There is, however, a strong illustration of choice in relation to an abstinence-based approach. The people of Alkali Lake, a Shuswap First Nation community in British Columbia, chose collectively to address its problems with alcohol by banning it altogether. The community “transformed its health conditions from within to suit its own self-defined needs."5 This is choice.

A false separation has been made between harm reduction and abstinence. This is because people tend to focus on the differences between the two approaches, rather than on what they have in common.

The two approaches, when applied in treatment, can both be offered together. Some abstinence-based NNADAP treatment centres, for example, accept clients while they are on methadone maintenance therapy, which is a type of harm reduction treatment. Another example is an Inuit substance abuse treatment centre in Ottawa, the Mamisarvik Healing Centre, which offers its clients the choice of either reducing their use or not using at all while in the treatment program.

Again, underlying all of these approaches is the common goal of helping people reduce the harm they experience because of their problematic substance use.

Harm reduction, abstinence—only part of any solution

So, is harm reduction a part of the solution to alcohol and drug abuse among Aboriginal peoples? To answer this, we must first accept what harm reduction is. We must then work toward solutions that effectively reduce the harms to individuals and communities suffering from the impact of substance abuse.

It’s also important to know that harm reduction and abstinence are only a part of any solution. Substance abuse is a symptom of past and present social ills and inequalities faced by First Nations, Inuit and Métis across the country. Respecting Aboriginal peoples and their culture, along with ensuring strengthened social, political and economic well-being, is at the core of reducing the harms of substance abuse.

When we fall into the line of thinking that pits harm reduction against abstinence, we need to remember that both can exist together. Supervised injection facilities, policies that limit access to alcohol, needle exchange programs, and not using substances at all are among the possible responses. It’s up to individuals, families and communities, who know their experiences and needs best, to decide. And, it is up to everyone else to be wise enough to accept their choice.

 
About the author

Colleen holds a Research Chair in Substance Abuse and Associate Professorship in Sociology and the School of Public Health at the University of Saskatchewan. She is also a Senior Research Associate with the Canadian Centre on Substance Abuse. Colleen’s work focuses on Aboriginal peoples’ health and wellness, women’s addictions programming, and youth inhalant abuse treatment

Footnotes:
  1. Public Health Agency of Canada. (2004, May). HIV/AIDS Among Injecting Drug Users in Canada (HIV/AIDS Epi Updates). Ottawa: Author. www.phac-aspc.gc.ca/publicat/epiu-aepi/epi_update_may_04/11-eng.php.

  2. Picard, Andre. (2008, February 1). HIV rate soars among Vancouver’s Native drug users. Globe and Mail, p. A11.

  3. Spittal, P., Hogg, R., Li, K. et al. (2006). Drastic elevations in mortality among female injection drug users in a Canadian setting. AIDS Care, 18(2), 101-108.

  4. Clement’s drug remarks ‘repugnant’: Doctor. The Canadian Press. (2008, August 20). www.ctv.ca/servlet/ArticleNews/story/CTVNews/20080820/clement_rx_080820/20080820?hub=Health.

  5. Dell, C. & Lyons, T. (2007). Harm reduction policies and programs for persons of Aboriginal descent (Harm reduction for special populations in Canada, No. 3). Ontario: Canadian Centre on Substance Abuse. www.ccsa.ca/NR/rdonlyres/9D021396-587C-4327-8FB7-42DDABCEED2E/0/ccsa0115152007.pdf.

 

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